CE Article: Beyond Ebola: Worldly Viruses Close to Home

Objectives

• Describe the viral life cycle and modes of viral transmission.
• Identify the epidemiology of chikungunya, dengue fever, MERS-CoV and West Nile virus.
• Highlight the potential U.S. impact of chikungunya, dengue fever, MERS-CoV and West Nile virus.
• Explain the importance of prehospital viral disease management and surveillance.

Over the past decade emerging viruses throughout the world have increasingly gained media attention. At different times pockets of U.S. healthcare systems have found themselves suddenly managing small outbreaks of viral diseases like swine and avian flu or ramping up for alarming possibilities like Ebola. While no U.S. Ebola outbreak has occurred, the latter has marked one of the very few widespread national and public prehospital planning efforts to prepare for a disease outbreak.

In truth, the odds of any U.S. prehospital provider encountering a patient with Ebola are quite low. There have been fewer than 12 suspected U.S. cases ever. However, there are many viruses that pose real threats to humans all over the world and that can be carried back into the United States. For example, following Haiti’s devastating 2010 earthquake, healthcare workers were exposed to cholera, leading to several outbreaks in the States. This month’s CE article explores the emergence and management of four viral diseases that have been brought back home: chikungunya, dengue fever, MERS-CoV and West Nile virus.

Viruses                                                  

Viruses are microscopic nucleic acids with a protein coat. Unlike many infectious pathogens, viruses are not alive. Living organisms can reproduce independently, and all viruses require the cells of other living organisms to replicate. The organism in which a virus replicates and grows is known as a host organism and could be a mammal, bird or reptile, etc. When outside of a host, some viruses will live and some will die, based on the structure and strength of their protein coat. All viruses are unique in their structure, and they’re often limited to surviving in just a few different organisms. For example, the avian flu virus H5N1 can infect and live in humans but not dogs or cats.

All viruses, regardless of their host organism, follow a similar life cycle (Figure 1). When a virus enters its host—for example, when we inhale a flu virus—it seeks out a cell and attaches to its target cell wall. Once the virus penetrates the cell wall, it integrates into the cell’s nucleus and changes its coding to replicate the virus components within the cell. When the virus has completed replicating inside the infected cell, the replicated viruses rupture through the cell wall (destroying the cell) and seek out new cells with which they can reproduce. The infected organism may or may not demonstrate symptoms of the viral infection until the virus grows to a significant quantity, often called the viral load. This period of asymptomatic viral growth is known as the incubation period.

Viruses move from host to host through either direct contact or indirectly through a vector. In human-to-human transmission, this can occur via water or fomite or airborne transmission or direct contact with an infected bodily fluid. When a secondary organism is needed to move the host from one organism to the next, that secondary organism is termed a vector. A vector is any insect or organism that transmits any pathogen from one organism to another. Most vectors are not seriously impaired by the virus, as it is to the virus’s advantage not to injure or kill an organism that helps it spread. Common virus vectors include mosquitos, which bite and feed on blood from an infected host and then carry the virus to other organisms and inject it when they feed again.

Figure 1: Following an exposure (Chikungunya in this case) of a virus, the viral growth process follows a predictable pattern. [COMP NOTE ART FROM FRAN]

Many viruses require days to weeks of incubation within humans before symptoms develop. It is now possible to reach any corner of the world within 24 hours. Thus, diseases that were previously often isolated to small corners of the world can now rapidly be carried anywhere if an unsuspecting individual is exposed and then travels during the incubation period.

Chikungunya

First identified in 1952 in Tanzania, chikungunya is an RNA alphavirus transmitted from human to human by mosquitos. Originally an Asian- and African-based disease, it has since emerged in Europe, the Caribbean and Latin America. Today the virus has been confirmed in more than 60 countries. While severely debilitating during disease progression, its mortality is low (0.4%).¹ There is an increased morbidity for both newborns and patients older than 65, as well as those with underlying diabetes, hypertension and cardiac disease.

Following exposure, chikungunya has a 10-day incubation period, and nearly all patients exposed become symptomatic. Most patients begin experiencing symptoms between days 3–7 following exposure, and always by day 12.² Among the first symptoms to appear are a fever as well as a large, flat, reddish maculopapular rash across the face, trunk and extremities. Soon patients begin experiencing arthralgia (severe joint pain). Arthralgia is considered symmetrical when it affects the same joints on both sides of the body. This arthralgia is often associated with crippling pain and can affect the muscles around the affected joint.¹ While its overall presentation is considered quite similar to dengue fever, the most significant difference is the presence of hemorrhage in dengue and severe joint point pain in chikungunya.

From 2013 through February 2014, there were nearly 300 chikungunya cases confirmed in Florida, a dozen declared as locally acquired, while another 1,000 cases occurred throughout the rest of the U.S. Fast-forward to February 2015, and there are now more than 2,492 confirmed cases within the United States and another 4,513 in its territories.³ In addition there are another 1,135,000 suspected cases between the Caribbean islands, Latin America and the United States.² Further, chikungunya is becoming increasingly common among U.S. travelers returning from affected regions, particularly Puerto Rico and the U.S. Virgin Islands.¹

The EMS Impact

Prehospital providers are the frontline of the healthcare system and often have the best vantage point to provide early disease surveillance, and this is best done by obtaining accurate international travel histories from patients with fevers. Patients experiencing sudden and severe joint pain, especially with a fever, may call 9-1-1 and request help. One of the best screening tools for any international disease such as chikungunya is to ask all patients with any suspected infectious process about recent travel to foreign countries or U.S. regions where these viruses have been confirmed.

Careful bloodborne pathogen protection is extremely important when treating suspected chikungunya patients, as blood-to-blood transmission is possible and has occurred with laboratory technicians who have mishandled infected blood.¹ Transmission from exposure to vomit, sweat, saliva and other bodily fluids has not been reported. Outside of laboratory exposures, the only known transmission route is a bite from an infected vector (mosquito).

Patients with chikungunya may be in severe pain, and their clinical treatment is symptom-based—there is no antiviral treatment available. Patients experiencing chikungunya are unlikely to have emergencies with their critical systems, so prehospital interventions focus on the symptoms. Antipyretics can be used to help reduce fever and are available in many oral forms. Patients can benefit from intravenous fluids as well as analgesics for their joint pain. Narcotic analgesia may be considered, and they also benefit from non-narcotic intravenous or intramuscular analgesics such as ketorolac.

Because the ongoing care of chikungunya is symptom-based, there is no need to transport these patients to specialized facilities. At the hospital blood samples may be sent to specialized laboratories for confirmation while patient care is handled locally. Most patients experiencing chikungunya have symptoms resolve within 1–2 weeks; however some degree of arthralgia can persist for months or even years.

Dengue Fever

A rapidly emerging and growing problem, dengue fever was first identified in the 1940s and infects up to 400 million persons annually.⁵ The World Health Organization considers it the world’s most significant mosquito-transmitted viral disease; it has experienced a 30-fold increase over the past 50 years.

Dengue is most commonly found in in the subtropic and tropical regions between 35 degrees north and 35 degrees south latitude. It’s transmitted by an Aedes mosquito that becomes a vector when it bites an infected individual and then feeds again on another human. Between 2001–11 there were small U.S. outbreaks in Texas, Florida and Hawaii.

There are four distinct dengue virus serotypes: DEN-1, DEN-2, DEN-3 and DEN-4. All four can infect humans, and prior exposure to one does not provide immunity to others. A first exposure to dengue often comes with no symptoms, and only later, when blood is sampled, are the antibodies discovered. However, subsequent exposures to dengue greatly increase a patient’s risk for developing dengue hemorrhagic fever and dengue shock syndrome. With treatment the mortality for dengue is less than 1%, but without appropriate care, severe dengue hemorrhagic fever has a mortality over 20%. Fortunately, to date, there have been no fatalities reported in the United States.

Following exposure from an infected mosquito, dengue incubates for 8–12 days. While patients may be asymptomatic, they can still transmit the virus to noninfected mosquitoes should they be bitten while the virus multiplies. When symptoms develop, they begin presenting on days 4–7 and last up to 10 days.⁴

Patients with dengue may be asymptomatic and can also have symptoms ranging from a mild fever to hemorrhagic shock. While all four serotypes of dengue can cause hemorrhagic fever, the risk factors increasing the chances for serious symptoms include young age, female gender, obesity, asthma, hypertension, diabetes and sickle-cell anemia. This makes diagnosis difficult, as it can only be confirmed in highly specialized laboratories; thus prehospital diagnosis is made based on clinical presentation and patient travel history.

Consider dengue hemorrhagic fever whenever a patient has been in an endemic region and then develops a high fever plus at least two of:⁴

• Severe headache;
• Severe eye pain (behind the eyes);
• Joint pain;
• Muscle/bone pain;
• Rash;
• Bleeding of the nose, gums, petechiae;
• Easy bruising.

Dengue hemorrhagic fever can present without bleeding, though that’s uncommon. Hemorrhage occurs as capillaries become excessively permeable during the viral exposure and fluid leaks from the circulatory system. Thrombocytopenia may also develop, further exacerbating bleeding. Hypotension, altered mental status and multiple organ dysfunction are indications a patient has progressed to dengue shock syndrome.

The EMS Impact

Because the Aedes mosquito varieties are not widespread in the United States, one may assume there is low risk for an outbreak here. The last U.S. outbreak occurred in 2005. Since then our climate has warmed, and as with the slow northern progression of Africanized honeybees, so too will a slowly warming planet allow Aedes mosquitos to move northward. Further, there are two large groups of travelers commonly returning from endemic regions: civilians and soldiers.

Consider anyone who has traveled in the prior 14 days to an endemic country and presents with symptoms a potential dengue fever patient. Dengue is found throughout Mexico, the Caribbean islands, South America, parts of Africa, India, southern China, Vietnam and most of the western Pacific islands. Most of these regions regularly have U.S. business and vacation travelers who can become exposed.

Further, dengue fever is a major threat to our troops serving in endemic regions. Following missions in Asian regions, dengue has affected as many as 80% of exposed troops, and the ill soldiers are often unable to serve for 3½ weeks!⁵ While there are no current conflicts in endemic regions, U.S. troops continue to serve and return home from throughout the world. As recently as 2008, 11% of sampled special forces soldiers were found to have dengue antibodies, signifying exposure may be higher than anticipated. Today dengue is considered the third-greatest infectious disease threat to solders, behind malaria and bacterial diarrhea.⁵

The prehospital care of a suspected dengue hemorrhagic fever patient initially focuses on a thorough and accurate history and physical exam. One additional noninvasive test that may help suggest dengue is a tourniquet test (see sidebar). Complete a full physical examination as well as neurological assessment to provide a baseline for future caregivers. Your complete history may provide the clues necessary for early disease recognition so that properly trained and experienced epidemiologists can be involved in patient care. Include in your history:

• Date of symptom onset (fever);
• Daily oral fluid intake;
• Presence and frequency of diarrhea;
• Urinary frequency and quantity (minimum is voiding every six hours).

During your detailed physical examination, include regular monitoring and trending of vital signs, especially respiratory and pulse rates. Identify and determine the spread rate of any rash, and examine all mucosal layers closely for evidence of hemorrhage. Patients with suspected or confirmed dengue may require transport to a specialized treatment center via ground or air, depending upon the distance.

Keep in mind that dengue hemorrhagic fever is a systemic and dynamic disease that affects multiple organ systems. The course of the patient’s illness and timing of access to medical care will significantly determine the seriousness of the symptoms you see. When treating patients with dengue fever, there are no known direct human-to-human transmission routes. This does not mean you can ignore standard precautions; rather it means routine patient care will not place caregivers at risk. The management of dengue is driven by its phase: febrile, critical or recovery.⁷

During the initial febrile phase, patients present with a high fever (greater than 38.5ºC) and at least two early symptoms. During this phase, the liver often enlarges by the third day, and mild mucosal bleeding may occur. Severe hemorrhage is not common but may develop in women of childbearing age (vaginal hemorrhage) and in the gastrointestinal tract. Patient care during this phase focuses on fluid administration in anticipation of fluid loss during the critical phase; fever control with antipyretics such as acetaminophen; and monitoring for febrile seizures (particularly in children). It is not possible to predict which patients will recover following the initial febrile phase or who will progress to the second phase.

Do not administer any suspected dengue patient acetylsalicylic acid, ibuprofen or any other nonsteroidal anti-inflammatory drug (NSAID), as these can worsen gastrointestinal hemorrhage.

Even with aggressive initial care, dengue can progress to its second critical phase, characterized by hemorrhage and plasma leakage that results in hypovolemia, pleural effusions, ascites, altered mental status, hypotension and cold extremities. While not all of these critical symptoms may present, this phase is diagnosed by at least one of the following: plasma leakage resulting in shock, fluid accumulation or respiratory distress; severe hemorrhage; or severe organ dysfunction. For most patients the critical phase lasts 24–28 hours. Dengue shock syndrome is present when the pulse pressure is  20 mmHg or less or a patient shows evidence of poor capillary perfusion. Patients in the critical phase should have intravenous isotonic fluids administered according to the following:⁷

• Initial: 5–7 mL/kg/hr for 1–2 hours;
• Then 3–5 mL/kg/hr for 2–4 hours;
• Then 2–3 mL/kg/hr and titrate to patient response.

When there is clinical evidence of shock, isotonic fluids at 5–10 mL/kg/hr for an hour, then 10–20 mL/kg/hr are indicated for 1–2 hours; then the patient will receive blood (if worsening) or decreased fluids (if improving). Critical care teams with laboratory data should monitor the patient’s hematocrit and hemoglobin, lactic acid and arterial blood gas every 30 minutes during transport until the patient is stabilized.

The third phase of dengue fever, the recovery phase, is marked by a rapid reversal of symptoms over 48–72 hours. However, the patient may experience several weeks of significant fatigue. Patients can experience bradycardia and ECG changes during this phase, but these will resolve without intervention.

The Tourniquet Test

Two large non-American studies demonstrated that a tourniquet test can aid in the diagnosis of dengue fever, with sensitivity near 56% and a specificity near 68%. The tourniquet test is performed on patients with a history of traveling to dengue-endemic regions and symptoms consistent with viral infection. To perform the tourniquet test:⁶

1. Place a blood pressure cuff on a patient’s arm and obtain the patient’s blood pressure;
2. Reinflate the cuff to a pressure between the patient’s systolic and diastolic pressures;
3. Leave the cuff inflated for five minutes;
4. Deflate the cuff and count the petechiae that develop in any square inch on the forearm distal to the blood pressure cuff;
5. If more than 20 petechiae appear in a square inch, the patient is highly suspected to have dengue.

MERS-CoV

The first reported transmission of Middle East Respiratory Syndrome (MERS) coronavirus, also known as MERS-CoV, to humans was reported in 2012, with the first case occurring in Saudi Arabia.⁸ While the virus is suspected to have originated in camels, as it has been cultured from their nasal secretions, this vector remains unproven. Since its discovery MERS has been confirmed in 22 countries throughout the Arabian Peninsula, and two separate U.S. patients have been treated for confirmed cases after returning from there. In addition, there have been more than 500 suspected cases throughout the U.S., and MERS-CoV has been confirmed in Italy, France and the United Kingdom.⁸ In just two years since discovery, nearly 300 cases have been confirmed, with a 90-day mortality rate of 58%. Most deaths occurred in individuals with comorbidities including diabetes, underlying lung disease, heart disease and kidney disease.

MERS is a coronavirus. This is a common group of viruses that cause mild to moderate infections of the upper respiratory tract. Coronaviruses are defined by their crownlike appearance, with spikes on their surface. Coronaviruses are also responsible for severe acute respiratory syndrome (SARS). Like other coronaviruses, MERS is transmitted from human to human through close personal contact such as coughing, sneezing, personal touch, shaking hands and performing medical procedures.

The true incubation time for MERS-CoV is not known, but based on reported cases it seems most patients develop symptoms 5–6 days following exposure. This can extend to 14 days. Patients who deteriorate to the point where intensive care unit care is required seem to deteriorate by the fifth day.

Following travel to the Arabian Peninsula or exposure to someone who traveled there, patients are considered possible MERS patients when they develop any of the following within 14 days: chills, body aches, sore throat, headache, diarrhea, nausea/vomiting and runny nose. Patients are highly likely to have MERS when they have the same exposure history and a fever plus pneumonia, acute respiratory distress syndrome or any other symptoms of respiratory illness.

The EMS Impact

There is significant potential for prehospital providers to encounter a patient with suspected MERS-CoV, as patients may incubate the virus for up to 14 days after returning from the Middle East. This has already occurred in two US healthcare workers who brought the virus back to the US with them. Patient care for MERS-CoV focuses on protection of critical systems and ensuring adequate oxygenation. In the few situations where advanced airway care is needed, avoid CPAP or BiPAP and instead consider early endotracheal intubation by rapid sequence intubation so that a HEPA filter can be easily applied to the exhaled air of a ventilator. Beyond airway, ventilation and oxygen management, patient care focuses on safety of the healthcare providers and appropriate safe transport to the proper facility.

Once a potential MERS case is identified, delay the transport process and isolate the patient where they are. Alert the emergency department and health department so a proper room can be prepared. While doing this ensure you don proper precautions. For MERS patients use standard precautions as well as airborne precautions including goggles and a HEPA-filtration N95 mask (or equivalent). All healthcare professionals who treat a suspected or confirmed MERS patient require 14 days of monitoring in the event of exposure. Please note, it is not known at what point a patient infected with MERS-CoV becomes contagious in relation to their symptom onset.

Once a receiving facility has been identified and readied, transport the patient with their surgical mask in place (if possible). It is acceptable to have this patient walk to the ambulance and sit on a bench seat to minimize your contact with them. Also ensure the transport vehicle is being actively ventilated. Have the fewest possible caregivers with the patient and do not allow any family/passengers in the same vehicle. During transport remain “upwind” of the patient’s exhalations, meaning sit in a safe seat and ensure air flows from the front to the rear of the ambulance. Air transport should be avoided when a long transport to a specialized facility is required. In situations where air medical transportation is required, utilize a fixed-wing pressurized aircraft to help maintain proper airflow. Helicopters cannot allow for adequate ventilation of the patient compartment.

Following transport, close the vehicle and allow the air to circulate at its maximum rate for at least one complete air exchange (up to 20–30 minutes depending on the ambulance size). Clean reusable equipment and the ambulance using an approved antiviral solution and following manufacturer’s recommendations.

West Nile Virus

The West Nile virus was first identified in 1937 in the Middle East and was found only in Africa, West Asia and the Middle East until 1999, when it was first confirmed in the United States. Today WNV is considered endemic throughout the U.S. and confirmed in all states except Maine.⁹  WNV is a single-stranded RNA flavivirus, which is a viral family also home to dengue, tickborne encephalitis and yellow fever. More than 65 mosquito species and several migratory birds are known vectors for West Nile virus, making it one of the more easily transmitted viruses.

Throughout the U.S., nearly 800,000 patients are suspected to be infected. Fortunately, while most are asymptomatic, more than 16,000 have had confirmed associated neurological illnesses including encephalitis and meningitis.⁹ As many as 20% of patients also present with mild symptoms including headache, weakness, body aches, arthralgia, vomiting, diarrhea and a maculopapular rash. When central nervous system involvement occurs, mortality can approach 10%.

There are three known human WNV transmission routes: mosquito, blood transfusion and organ transplantation. The risk of the latter two has been greatly reduced, if not eliminated, by routine testing of donated blood and organs. Before screening, blood transfusion transmissions exceeded 2.7 cases per 10,000 units.¹⁰ Mosquito transmission is heavily driven by their population and most frequently occurs in the late summer and early fall.

Following exposure, there is a 3–14-day incubation period. Following incubation, most patients will remain asymptomatic or have such mild symptoms that the patient doesn’t associate them with the virus. Patients with mild symptoms are unlikely to encounter EMS or any other level of healthcare provider. However, when symptoms of neuroinvasive disease develop, EMS is likely to see acutely deteriorating patients.

West Nile virus neuroinvasive disease can manifest in three forms as WNV crosses the blood/brain barrier, resulting in deep penetration into the central nervous system. All CNS presentations are associated with fever: meningitis, encephalitis and acute flaccid paralysis. WNV-based meningitis presents identically to any other viral meningitis, with high fever, nuchal rigidity and headache. Encephalitis caused by WNV tends to be severe, resulting in seizures, movement disorders similar to Parkinson’s (tremors) and altered mental status. Patients progressing to flaccid paralysis most often have underlying chronic illnesses or depressed immune systems, and may see lower-extremity paralysis extend to the upper extremities as well as respiratory muscles, resulting in the need for ventilator support.

The EMS Impact

Since West Nile virus cannot be easily transmitted from human to human and patient care is 100% symptom-driven, it is tempting to claim WNV has little to no EMS impact. However, once again EMS is at the frontline of disease recognition. A sudden increase in regional flulike symptoms following an increase in mosquito activity may suggest WNV. Further, when serious symptoms develop, the median days of work missed exceeds 16, making the potential impact to prehospital providers profound. Since West Nile virus is present in 47 of the contiguous states, nearly all prehospital providers risk being exposed to it.

There is no specific antiviral intervention for West Nile virus; prehospital and hospital interventions are 100% based on patient history and presentation. It is unlikely the patient’s critical systems will require stabilization, but if one does, it is most likely to be the nervous system. Patients are most likely to require care for their fever as well as potentially pain and nausea. Consider administration of antipyretics, non-narcotic analgesics and antiemetics.

A Global Approach

Healthcare is now a global system, and diseases and illnesses once isolated to the far reaches of the earth can no longer be considered unimportant for U.S. healthcare professionals. Set yourself up for success by adopting a practice of screening all patients with infectious-based complaints for any travel. When travel is included in the patient’s recent history, have a low threshold for requesting additional resources and alerting your healthcare system to a possible emerging illness. It’s only through an early alert and careful surveillance for these patients that we can prevent widespread infections.

Maintain open conversations with your peers locally and throughout your region and the country. While respecting patient privacy rights, don’t be afraid to share patterns of symptoms and illnesses. It is only through sharing and reporting that disease clusters can be identified. Prehospital providers are well positioned to be the first to identify patients with these emerging illnesses.

If you are exposed, do not hesitate to speak up. Allow your employer and healthcare system to work with you to provide necessary post-exposure care. Unfortunately there is no post-exposure prophylaxis for most viral-based disease; however, it is important to provide careful monitoring for the first signs of symptoms.

Last fall’s Ebola patients were a great reminder that international illnesses can be brought back to the United States. But Ebola remains only one of many worrisome and dangerous diseases from around the world that put us at risk. Chikungunya, dengue fever, MERS-CoV and West Nile have all been diagnosed in the United States, and it’s only a matter of when they present again. Rare exposure does not mean low-risk exposure. These viruses pose a real risk to healthcare providers, and it’s only through monitoring, patient history-taking and a high index of suspicion that we can minimize it.

References

1. Centers for Disease Control and Prevention. Chikungunya virus: Geographic Distribution, www.cdc.gov/chikungunya/geo/index.html.

2. World Health Organization. Chikungunya, www.who.int/mediacentre/factsheets/fs327/en/.

3. Centers for Disease Control and Prevention. Chikungunya virus: 2014 Provisional data for the United States, www.cdc.gov/chikungunya/geo/united-states-2014.html.

4. Centers for Disease Control and Prevention. Dengue, https://www.cdc.gov/dengue/.

5. Gibbons RV, Streitz M, Babina T, et al. Dengue and U.S. military operations from the Spanish-American War through today. Emerg Infect Dis, 2012 Apr; 18(4): 623–30.

6. Halsey ES, Vilcarromero S, Forshey BM, et al. Performance of the tourniquet test for diagnosing dengue in Peru. Amer J Tropical Med Hygiene, 2013; 89(1): 99–104.

7. World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control, www.who.int/tdr/publications/documents/dengue-diagnosis.pdf.

8. Centers for Disease Control and Prevention. Middle East Respiratory Syndrome, www.cdc.gov/coronavirus/mers/about/index.html.

9. Centers for Disease Control and Prevention. West Nile Virus, www.cdc.gov/westnile/index.html.

10. Stramer SL, Fang CT, Foster GA, et al. West Nile virus among blood donors in the United States, 2003 and 2004. N Engl J Med, 2005; 353: 451.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also the clinical education coordinator for AirLink/VitaLink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. Contact him at ktcollopy@gmail.com.

Sean M. Kivlehan, MD, MPH, NREMT-P, is the emergency medicine chief resident at the University of California San Francisco and a former New York City paramedic for 10 years. Contact him at sean.kivlehan@gmail.com.

Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. He is also a paramedic with AMR: Sonoma Life Support in Santa Rosa, CA. E-mail scottrsnyder@me.com.